What an old doctor taught me about palliative care

Many years ago when I was a “young” doctor, moonlighting in the ER of a tiny country town, I had an experience that challenged my training. You see, most young, new doctors often think their training and knowledge is superior to that of “old” doctors, which is often malarkey. A wise and sage old doctor in this tiny country town taught me an important lesson on where and how one should die.

I had just walked in for my second moonlighting shift in this small 5 bed ER when the paramedics buzzed by me “bagging” (artificially ventilating) a small elderly lady. All I saw of her as they whizzed by was a dangling pale arm and dyed blue-black hair perfectly coiffed with shiny pin in place.

“Well come on in here, Dr. Murphy,” the charge nurse said as she motioned me into the trauma room of this little ER.

The paramedics gave me a quick report, “She just fell over unresponsive at the beauty parlor (southern term for hair salon). All of the ladies were screaming when we arrived and all she has is a gag reflex as far as we can tell. Her blood pressure is up but heart rate is normal. Whatcha think, doc?”

“Head bleed (slang medical term for intracranial hemorrhage),” I said as I quickly checked her pupils and lack of response to a brisk sternal rub.

“That’s what we were thinkin’ too, doc.” The lead paramedic replied. “And, by the way, the family is on the way.”

Since I was a young doctor with a whole lot of book sense but very little common sense, I proceeded to intubate her, CT scan her and arrange for her helicopter flight to our larger regional hospital, all without asking the family about her wishes or advance directives, or even what their desires for her might be.

All I told the family was something like this: “She has a very large amount of bleeding in her brain, this made her faint and now she is unresponsive. I had to put her on a life support machine and now we’ll need to fly her to our regional hospital so the brain specialist (neurosurgeon) can see her. I can tell you that this doesn’t look good.” (At least I had enough sense to tell them that the situation was grave.)

Basically, my conversation was about what I had already “done to her” and what else we were going to “do to her.” This is too often how doctors and medicine function. You end up in the ER and we place you on the medical train and tell you where the next stop is — without asking your opinion or your family’s opinion about our itinerary.

Fortunately, one of the family members had something to say, “Would you mind calling her family doctor to let him know?”

“Of course!” I responded, “Absolutely, I will call him now.”

So, I got him on the phone.

“Dr. Crane, this is a courtesy call to let you know that your patient, Mrs. P, 75-year-old female, came in unresponsive with a massive head bleed. I am flying her to our regional hospital and I wanted to let you know. I have spoken with the family and they are all here.”

Dr. Crane said, “Pull up the CT scan and I will be right there.”

Almost as soon as I hung up and put up the images, he came around the corner.

Dr. Crane looked about 75 himself, and was very striking, with gleaming white hair and glasses framing his bright green eyes.

He shook my hand and at the same time he began to review the images.

“Mmm … hmm,” he said as he examined the images carefully. Then, he turned to give me an unusual look, while pushing his glasses up to rest on his head. It was the same look that my grandmother used to give me when she wanted to gently correct me. I recognized it, but didn’t have the foggiest notion what he was about to say.

“Listen here young doct-uh (southern drawl for “doctor”). With all due respect, I know that you are doing what you were trained to do, but this lady isn’t going anywhere.”

Slightly startled, I asked him, “What do you mean?”

Then came the lesson.

He said, “You see, Mrs. P was born in this town. I have been her doctor for 30 years. Her whole family lives here. She has lived here for all of her 75 years. So, there is no reason for her to die in any other place. Ain’t nobody gonna survive a head bleed that big anyway. There is no reason to send her and her family 90 miles away so that she can die in a strange place, a strange city. It doesn’t do anybody any good. So, we are going to keep her here and keep her comfortable. Her whole family and her whole community can be with her. That’s the right thing to do. Don’t you think?”

I stood very quietly, even reverently.

Then, I said, “Yes, sir.”

I recognized that I was standing in the shadow of a real doctor. I watched as he sat with Mrs. P’s family and held their hands. They all cried together and then he wrote admission orders, and extubation orders.

I cancelled the helicopter, and began to hope that one day I would grow up to be like “old” Dr. Crane.

Monica Williams-Murphy is an emergency physician and author of It’s OK to Die.

What an old doctor taught me about palliative care 11 comments

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ninguem

MANY a time I’ve seen that in hospitals.

Actually, what I’ve seen, probably as much, is the consultant really doesn’t want to intervene in what’s really an impossible situation.

The family won’t hear it, until they’ve heard it from their family doctor.

NewMexicoRam

Wow.
In my experience, the family won’t hear it until they hear it from a specialist.

ninguem

I agree, usually it’s the other way.

But these terminal “turn off the ventilator” cases, often the family has to hear it from the primary doc.

David Gelber MD

it is very common that I am called to see patients with hopeless, terminal conditions, other consultants expecting me to rush the patient to surgery. I’ve often been the doctor who has to inform the patient’s family that nothing can be done. Most of the time they are appreciative of the honesty.

May be worth noting that the “real doctor” did not consult with the patient or family, made the decision on what to “do to her” all by himself, and informed the family after the fact on what was “done to her”. The only difference here is that he was “her” doctor for 30 years.

I would like to point out that it is GREAt that the doctor has known his patients for 30yrs, however this is not necessary to still have a good knowledge and relationship with the patient and family.

All that is really needed is for the Family Doctor to spend more time and effort in knowing his patient and their desires and needs. Honestly, this can be done in relatively few good personal visits.

Yes, the heart and soul of Family medicine. AAFP would “save” itself if it could understand that our role as Family doctors is more advocate and confidant than “cold and flu management” and would actually put it’s efforts into lobbying for proper support of this role. Instead they are to focused on propagating the Mcmedicine model of increasing family doctors “productivity”.

Disqus_37216b4O

Another reason to mourn the loss of the family doctor.

In the new paradigm, where a patient is cared for by an ever-changing rotation of miscellaneous “providers” and may never even see the actual doctor who’s running the practice, and where patients unfortunate enough to end up in hospital are shunted off to a “hospitalist” who doesn’t know thing one about them, there will be no one doctor who has their finger on the pulse (so to speak) of any given patient (unless said patient was rich enough to buy their way into a concierge practice).

The increasing fragmentation of medical care means that treatment like this lady was fortunate enough to enjoy is going to be relegated to the history books.

Rob Burnside

If it’ll help, I’ll tell you about the time when –fresh out of EMT training–I attempted to place a Hare Traction Splint on a prosthesis. Fortunately, or unfortunately, this occurred in his family physician’s office. Kindly old Dr. K. simply tapped me on the shoulder and whispered, “I don’t think that will work very well. Why don’t you just take him to the hospital.” (It was right across the street) I was clearly wrong. You weren’t. Big difference!

Rob Burnside

Back then QW, we were considered “Allied Health Care” personnel, though the nurses were almost always nice to us (because we always helped them when we could, and some of us actually worked part-time in the ER) and the docs with “big city” ER experience, who knew what we were capable of, considered us their front men. Working together, we saved a lot of patients who wouldn’t have made it otherwise,

querywoman

Healing has always been a shared responsibility.

Rob Burnside

Right again, QW–teamwork is where it’s at. The bickering and fragmentation I see in health care today frightens me a little. Hopefully, it’ll change.